I like Twitter.

I stress the word like because I find it useful for some things, but not so useful for many others. This doesn’t mean that I don’t believe in it’s power or it’s influence, just that I recognize the limitations the tool has and my expectations don’t exceed it. It’s important to remember that as you read on.

So in the same vain of answering Greg’s question, I am now going to answer a question most recently asked by Steve Whitehead on Twitter that deserves more than 140 characters will allow:

Can The Real Protocol Please Step Forward?

There is a reason why medicine is still considered an art.

You can have two patients with the same complaint, but because of having vastly different histories the same treatment applied to both may help one but harm the other.

This is one of the reasons why you will find some vastly different protocols across the country. What works well for some areas may not work well for others, and what works well for some patients may also not work well for others.

In My Experience

It’s important to understand that I am New York State Certified, so my experiences are limited to working within NYS Protocols. On the fifth page of those protocols under the Introduction heading appears this paragraph:

God bless the New York State Department Of Health Bureau of EMS.
The Continuing Problem

Unfortunately, even with that paragraph there, it still leads to problems. EMT recruitment is as easy as checking the ABCs. If you’ve got a pulse and can breathe you can become an EMT. The current education is centered around the protocols and complying with them as opposed to independent thinking with good clinical judgement, because by not following them you run the risk of being held liable if anything goes wrong with the patient.

Why is that 90 year old patient with osteoporosis strapped to a backboard after falling out of bed? Protocol.

Why is that hyper-ventilating patient suffering from an anxiety attack wearing a non-rebreather set to 15 liters per minute? Protocol.

Why is that patient sitting on a roadside construction sign (next to the car he was in when rear ended ever so slightly and obviously got out of) being strapped into a soft Spinal Immobilization Vest? Protocol.

Burn The Protocol Book, Care For Them All, Let The Triage Nurse Sort It Out

I once had a paramedic who would always refer back to the protocol book. If you were turning cyanotic and gasping for breathe in the tripod position in front of him, he would take a minute to look it up in the protocol book before giving you some much needed oxygen. This over reliance on protocol is a bad indicator that our education model needs to be revamped, our recruitment methods are not working, and that we are more concerned with the potential lawsuit down the road than we are the patient in front of us.

If that paragraph didn’t exist in the NYS Protocols, I probably wouldn’t be in EMS anymore today. Heck, I probably wouldn’t have made it out of my first year because strapping down 90 year old patients with osteoporosis is just not something I think I could actually do with or without legal “justification”.

Which is another thing I blame protocol for. EMTs and Paramedics use protocols as justification for providing treatment that doesn’t benefit the patient, but benefits them. Such as taking the patient to the nearest hospital as opposed to the hospital the patient has a doctor at. Sure in a perfect world hospitals would be able to share records, test results, and other information… but right now they can’t. It’s a major shortfall of the healthcare system that we won’t be able to solve, but for that specific patient we may be able to alleviate that issue as well as some anxiety by simply taking them the extra mile (or five) to where they already have received treatment.

Finally, I hate protocol because so many people think that providing patient care is a black and white issue when it is far more complicated than that. Sure protocol can provide you guidance on the basic treatment a patient should receive, but it doesn’t provide you with a methodology or the tools to provide exceptional patient care. As I said before, there is a difference between treating and caring for your patients. Which one would you rather do? Which one would you rather be on the receiving end of?

I say burn the protocol book, care for them all, and let the triage nurse sort it out.